Provider Demographics
NPI:1114067196
Name:KINGDON, KENNETH MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:MICHAEL
Last Name:KINGDON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6330 GRANADA WAY
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78257-1733
Mailing Address - Country:US
Mailing Address - Phone:619-300-2289
Mailing Address - Fax:
Practice Address - Street 1:3100 AVENUE E
Practice Address - Street 2:
Practice Address - City:HONDO
Practice Address - State:TX
Practice Address - Zip Code:78861-3534
Practice Address - Country:US
Practice Address - Phone:830-426-7723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP4471208600000X, 2086S0127X, 207P00000X, 207Q00000X
IL036.126385208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036126885Medicaid
IL214881172Medicare PIN
IL036126885Medicaid